Advances in targeted closed loop spinal cord stimulation to treat pain of the trunk and limbs

ABSTRACT Introduction Traditional open-loop SCS is confronted by several major challenges. Variable inconsistent activation of the intended target results in the inconsistency of treatment outcomes and the programming of fixed-output devices below the sensation threshold may not activate dorsal column axons. Closed-loop SCS (CL-SCS) using evoked compound action potential (ECAP) has overcome these limitations with the ability to measure spinal cord activation and accurately administer therapeutic doses despite the dynamic physiologic processes that affect SCS therapy delivery. Areas covered The authors present a comprehensive review of CL-SCS treatment and ECAP controlled effects demonstrating long-term benefits and cost-effectiveness compared to fixed output SCS for patients with chronic intractable trunk and limb pain. Several studies have been highlighted by the authors demonstrating superiority in both pain relief and universal treatment responses of ECAP- controlled CL-SCS in comparison to fixed-output open-loop SCS. Expert opinion ECAP dose-controlled CL-SCS delivers promising clinical benefits by providing precise, objective control of SCS dosing, aligning with outcomes observed in both RCT and real-world settings. The incorporation of neural metrics into the programming process offers a transparent and reproducible framework for optimizing therapy, enhancing pain relief, and improving universal patient outcomes.